The Journal of Urology
Volume 177, Issue 3 , Pages 809-811, March 2007

This Month in Clinical Urology

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Pelvic Lymph Node Dissection for Penile Carcinoma 

A major issue in the management of penile carcinoma is the inaccuracy of clinical lymph node staging. About 20% of patients with clinically node negative disease have occult inguinal metastases and about 30% with inguinal involvement have tumor positive pelvic nodes. To identify pathological parameters of inguinal lymph node involvement, and predict pelvic lymph node involvement and survival, Lont et al (page 947) from Amsterdam, the Netherlands assessed 308 patients with penile carcinoma and adequate followup. The outcomes of 102 patients who underwent lymphadenectomy for lymph node metastases were analyzed further. Tumor grade and number of involved inguinal lymph nodes were independent prognostic factors for pelvic lymph node involvement. Extracapsular growth, bilateral inguinal involvement and pelvic lymph node involvement were independent prognostic factors for disease specific survival. The authors conclude that patients with only 1 or 2 inguinal lymph nodes involved without extracapsular growth and no poorly differential tumor within those nodes are at low risk for pelvic lymph node involvement, and have a good prognosis with a 5-year survival rate of about 90%. Pelvic lymph node dissection seems unnecessary in these patients.

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Efficacy of α-Blockers for Ureteral Stones 

α-Blockers are a promising class of stone expulsive agents, and the proposed mechanism is selective relaxation of ureteral smooth muscle with subsequent inhibition of ureteral spasms and dilatation of the ureteral lumen. To determine if α-blocker therapy promotes expulsion of ureteral stones, Parsons et al (page 983) from San Diego, California performed a meta-analysis of 11 randomized clinical trials of α-blockers for the treatment of ureteral stones. Pooled analysis demonstrated significantly increased stone expulsion rates with α-blocker therapy. Compared to patients receiving conservative therapy only, those receiving conservative therapy plus α-blockers were 44% more likely to spontaneously expel the stones and stone expulsion incidence increased significantly. Sensitivity and subgroup analyses categorized by specific α-blocker, prior use of shock wave lithotripsy and stone size produced similar effect estimates but were generally less precise due to smaller sample sizes.

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Prediction Model for Low Volume/Low Grade Cancer 

Ochiai et al (page 907) from Houston, Texas previously developed a model for predicting low volume/low grade cancer in men undergoing radical prostatectomy with extended prostate biopsy. In men with 1 positive core the model that incorporated tumor length in a core, Gleason score and prostate volume significantly enhanced the prediction for low volume/low grade cancer. However, their model was not validated in an independent patient population. In the current report the authors applied their prediction model to an external patient data set to test its diagnostic accuracy. The study included 170 men who had undergone radical prostatectomy without neoadjuvant therapy. In all instances prostate cancer was diagnosed in only 1 positive core of a 10-core extended biopsy. Model accuracy was assessed which consisted of tumor length less than 2 mm, Gleason score 3+4 or less and prostate gland volume greater than 50 cc in predicting the occurrence of low volume/low grade cancer (defined as tumor volume less than 0.5 cc, no Gleason grade 4 or 5 disease, and organ confined disease). Of the patients 101 (59.4%) had low volume/low grade cancer. The model using all 3 variables had the highest performance, demonstrating a positive predictive value of 70.4%, a negative predictive value of 71.1% and a diagnostic accuracy of 70.6%. This model performed better than one based on tumor length only or one based on tumor length and Gleason score. The authors believe the model can be used as a tool for selecting men for active surveillance.

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Minimally Invasive Treatment of Ureteropelvic Junction Obstruction 

In the 1980s endourological techniques were established as minimally invasive alternatives to open pyeloplasty. However, the success rates varied between 43% and 89% depending on the underlying pathology. Rassweiler et al (page 1000) from Heidelberg, Germany present their long-term experience with the efficacy of ureteroscopic laser endopyelotomy (LEP) and laparoscopic retroperitoneal pyeloplasty (LAP). From February 1995 to March 2006, 256 patients with ureteropelvic junction obstruction (UPJO) were treated with LEP (113) or LAP (143). According to changing selection criteria, an early group (1995 to 1999) treated with LEP for extrinsic as well as intrinsic stenosis and a late group (2000 to 2006) treated with LEP for intrinsic stenosis were evaluated. In the late group extrinsic UPJO was treated with nondismembered pyeloplasty in cases of anteriorly crossing vessels and with dismembered pyeloplasty in cases of posteriorly crossing vessels in a redundant renal pelvis. LEP operating time averaged 34 minutes (range 10 to 90) with a complication rate of 5.3% and a success rate of 72.6% (intrinsic 85.7%, extrinsic 51.4%). LAP operating time averaged 124 minutes (range 37 to 368) with a 6.3% complication rate and a 94.4% overall success rate (intrinsic 100%, extrinsic 93.8%). In the early group the LEP success rate was 98.3% with no significant differences related to the cause of UPJO or the type of pyeloplasty. LAP yields an efficacy similar to that of open surgery. The inferior success of laser endopyelotomy even in optimally selected cases and the increasing expertise with endoscopic suturing may favor laparoscopic pyeloplasty with or without robotic assistance in the future.

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Tandem Transcorporal Artificial Sphincter Cuff Salvage Technique 

Several techniques have been reported for salvage of artificial urinary sphincter (AUS) implantation due to nonmechanical failure including tandem cuff placement, cuff downsizing and cuff relocation. Combining the approach of tandem AUS cuff configuration with transcorporal placement in the salvage setting provides an attractive option when surgical planes are effaced and the risk of urethral injury is high. Magera and Elliott (page 1015) from Rochester, Minnesota report on their retrospective analysis from July 2002 to December 2005 of 18 patients who underwent tandem transcorporal salvage AUS surgery with 1 (10 of 18) or both (8 of 18) cuffs placed transcorporally. Etiology of previous AUS failure leading to insertion of both cuffs in the transcorporal position included 3 infections, 2 erosions, 2 impending erosions and 1 failed male sling. A self-administered standardized questionnaire was used to assess continence and quality of life outcomes. At a median followup of 26 months, pad use decreased from a median of 5.0 to 2.0. Two patients experienced explantation of the device (1 erosion, 1 infection) without reimplantation and were excluded from outcome analysis. Eleven patients (69%) required 2 or fewer pads daily and 5 (31%) required 3 pads daily, and all 11 described the condition as very or extremely improved. Of the 5 patients reporting some or no improvement 4 were also on androgen deprivation therapy, suggesting that the transcorporal technique may be less durable. The authors conclude that tandem transcorporal AUS placement is an effective approach to salvage cases with a high risk of repeat erosion or infection after failed AUS placement.

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Transurethral Sphincterotomy for Autonomic Dysreflexia in Spinal Cord Injured Men 

Paroxysmal hypertension, referred to as autonomic hyperreflexia with pounding headache, is the usual presenting symptom of autonomic dysreflexia (AD). This condition is often accompanied by perfuse sweating above the level of injury, flushing of the face, piloerection, bradycardia and sometimes tachycardia. Perkash (page 1026) from Palo Alto, California describes his experience using laser transurethral sphincterotomy (TURS) in 46 consecutive spinal cord injured (SCI) males presenting with frequent symptoms of AD and inadequate voiding. Selection criteria included injuries above T6 and subjective symptoms of AD in patients who did not want to be catheterized or were unable to perform intermittent catheterization. There was considerable relief in AD following TURS in all patients, which correlated well with a significant decrease in systolic and diastolic blood pressure. Mean post-void residual urine decreased from 233 ± 151 to 136 ± 35 ml after TURS. No significant change was noted in mean maximum voiding pressure. Blood pressure monitoring during cystometrogram provides an objective assessment of the presence of AD due to neurogenic bladder dysfunction, enabling better therapeutic management. (CME credit article)

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Correlates to the Clinical Diagnosis of Premature Ejaculation 

Premature ejaculation (PE) is a common male sexual dysfunction worldwide. A typical approach for assigning PE status in clinical trials is stopwatch measured intravaginal ejaculatory latency time (IELT), which is also often used in clinical trials for the evaluation of and treatment for PE. In clinical practice it is not practical for patients to provide a stopwatch measured IELT, and so it is provided as a self-estimate. In a multi-institutional study Rosen et al (page 1059) characterized IELT and single item patient reported outcome (PRO) measures in a large population of men with (207) and without (1,380) PE and their female partners. Estimated and measured IELT, age, and responses to single item (control over ejaculation, personal distress, satisfaction with sexual intercourse and interpersonal difficulty) and multiple item (male and female Golombok-Rust Inventory of Sexual Satisfaction, male Self-Esteem And Relationship and Short-Form 36) measures were evaluated with stepwise logistic regression analysis. Self-estimated and stopwatch measured IELT were interchangeable, correctly assigning PE status with 80% sensitivity and 80% specificity, increasing to 96% specificity when combined with single item PROs. Subject reported control over ejaculation and personal distress most strongly indicated PE status. Partner personal distress was more influential in determining PE status than estimated or measured IELT, and single item measures were more influential than multiple item measures. Neither self-estimated nor stopwatch measured IELT alone was optimal for assigning PE status. Subject and partner responses to single item measures, particularly control over ejaculation and personal distress, were important. Results suggest that a combination of estimated IELT and the 4 single item, subject reported PRO measures can adequately identify PE status. (CME credit article)

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Pattern of Recurrence Changes in Noninvasive Bladder Tumors 

It is well recognized that low and moderate grade superficial transitional cell tumors of the bladder require regular followup but the surveillance duration has not been clearly established. To address this question Mariappan et al (page 867) from Edinburgh, the United Kingdom accessed a large database prospectively kept and maintained for 25 years to validate previously published trends in cohorts of patients initially treated at another institution during a similar time frame (1978 to 1986) and in a more contemporary cohort of patients with G1Ta, G2Ta disease diagnosed between 1991 and 1996. In all cohorts the risk of recurrence at 3 months was higher for those with multifocal disease. Tumor evident at 3 months was consistently the strongest predictor of recurrence thereafter. The pattern of recurrence in all validation cohorts of this study seems to be similar to that previously observed and published. When comparing patients with G1Ta disease with a first recurrence after being tumor-free for 1 year, the risk was 38% in the cohorts from the 1990s and only 19% in the cohorts from the 1980s. If G1Ta and G2Ta tumors are considered and analyzed as low risk tumors together, the risk of first time recurrence after year 5 was 3.2% for the 1980s cohort and 10.8% for the 1990s cohort. The authors speculate that the increased reliance on flexible cystoscopy may have altered the threshold to biopsy, resulting in delayed biopsy proven recurrence, albeit with no disease progression. Until highly sensitive and specific urine based markers become widely available for clinical practice, long-term cystoscopic surveillance may need to be continued. Nevertheless, since there were no instances of delayed progression stopping regular cystoscopic surveillance after being tumor-free for the first 5 years appears to be safe. (CME credit article)

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Botulinum Toxin Type A Injections do not Induce Vesicoureteral Reflux 

Botulinum toxin A (BTA) injections into the bladder wall have been shown to be effective in treating neurogenic overactive bladder (OAB). Evidence is growing that BTA injections within the bladder wall act not only on efferent cholinergic nerve endings, which induces uninhibited detrusor contractions by acetylcholine release, but also on afferent neural pathways arising from the bladder. Karsenty et al (page 1011) from Montreal, Quebec, Canada assessed the manifestations in vesicoureteral reflux (VUR) grade before and after injection of 200 units of BTA into the detrusor in 10 sites on the bladder base including the trigone of patients with refractory idiopathic OAB to determine if VUR was induced by the treatment. Injection induced pain and short-term efficacy were also evaluated. Twelve women were enrolled in the study (median age 76 years) in whom behavioral treatments, pelvic floor exercises, medication and neuromodulation had failed. In addition to a history, and physical and urodynamic evaluation, videourodynamics were performed 1 hour before the injection and 6 weeks after treatment. One patient was excluded from analysis because of a urinary tract infection, 10 women had no VUR at baseline and 1 had bilateral VUR (grade II right, grade I left). At 6 weeks there was no induced VUR and the patient with VUR at baseline showed no change in VUR grade. No local or systemic side effects related to BTA were reported. In terms of efficacy, on direct questioning 6 weeks after treatment 4 of the 11 patients reported improvement that led them to ask for another injection. BTA injections into the trigone do not induce de novo VUR in patients with nonneurogenic OAB. The therapeutic value of this approach remains to be confirmed and compared to other injection designs. (CME credit article)

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Association of Testis Derived Transcript Gene Variants and Prostate Cancer Risk 

Many genetic factors are believed to be involved with prostate cancer. For example, chromosome 7q31 has commonly exhibited loss of heterozygosity in prostate cancer and other tumor types. Allelic imbalance of 7q31.1 is also associated with poor outcome in patients with prostate cancer. Moreover, the 7q31-33 region has been linked to prostate cancer aggressiveness. The testis derived transcript (TES) has been suggested as a tumor suppressor gene for prostate cancer at 7q31. To further investigate this observation, Liu et al (page 894) evaluated the effects of 7 tagging single nucleotide polymorphisms (SNPs) that comprehensively captured the common genetic variants in TES in a case control study. A total of 506 men diagnosed with aggressive prostate cancer and an equal number of age, institute and ethnically matched controls were assessed. A logistic regression model was used to evaluate the association between SNPs/multimarker haplotypes and prostate cancer. No statistically significant associations were observed between any variants and more aggressive disease in all study subjects and white males. In black men 2 highly correlated SNPs were inversely associated with prostate cancer. The haplotype analysis for these 2 SNPs did not improve the genotype level results. The findings suggest that the variants in the TES gene or in a nearby gene may be associated with prostate cancer in black men. (CME credit article)

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Book Review 

On page 1207 Curigliano and Spitaleri review Drug Treatment in Urology.

PII: S0022-5347(06)03078-3

doi:10.1016/j.juro.2006.11.045

The Journal of Urology
Volume 177, Issue 3 , Pages 809-811, March 2007

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